OREGON DEPARTMENT OF STATE LANDS

UNCLAIMED PROPERTY SECTION

775 SUMMER STREET NE, SUITE 100
SALEM OR 97301-1279 Claim ID: 500143878

12/25/2020

HOLLIS BROWN
2113 NORIK DR
MODESTO, CA 95355-9155

A. Claimant Information
Name (s) if different than above: Daytime Phone: (909) 653-7012

Current Mailing Address if different than above:

Last 4 Digits of
Email Address: hollisbrown83@gmail.com
SSN/Tax ID:

B. Documentation Required
You must submit all documents in the following list with this completed claim form. If we do not receive a
response from you within ninety (90) days from the date of this claim form, your claim will automatically be
dropped from our system, and a new claim would need to be filed. After review, additional documents may
be requested.

Death Proof Verification of death for your relative such as a death

certificate, obituary, funeral home records or a memory card.

Photo Identification All signers should provide a copy of the front and back of
their current photo identification, which may include your
driver’s license or other government issued ID.

Heir Relationship You are claiming assets as an heir to a deceased person.

Please provide documentation supporting your relationship to
the decedent. Examples might include birth, marriage or
death certificates and/or obituaries.

SSN A copy of your Social Security number or a document which

shows this number, such as tax return, bank statement, pay
stub, etc. (You are not legally required to provide your Social
Security number, but we request that you do so voluntarily to
assist us in determining whether you are the rightful owner of
the account.)

Address Link Relative Provide evidence linking your relative to the address(s) listed.
Examples might include old statement, mail, DMV records,
address history, etc. If proof is not available, provide written
explanation confirming their time period of residency.

Address-Current Provide evidence of your current mailing address. Examples

might include utility bill or statement.

Signature Please provide all required signature(s) on the claim.

 Claim ID: 500143878
C. Property Information
Reported Owner(s) and Property ID / Last
Type of Property Value
Address(es) Activity Date

BROWN J
997352
, OR REFUNDS DUE $50.00 or Greater
08/18/1997
SELF

D. Security Information
Not Applicable
E. Affidavit

I declare under penalty of perjury and/or mail fraud that I have provided true and correct information
regarding my claim and to the best of my knowledge I am entitled to the assets of this claim. Upon payment
of this claim, I agree to indemnify the Oregon Department of State Lands (DSL) and hold it harmless for and
from all claims, loss, costs, damages and expenses that DSL may sustain by turning this asset over to me, or
of its refusal to pay this asset or any part of it to any other person or persons.

Signature of Claimant Date

Additional Claimant Signature (if Applicable) Date

Final Instructions
Please return the completed claim form along with the documentation listed in Section B to our office at your
earliest convenience.

• You may upload the claim form and documentation via our website at
https://unclaimed.oregon.gov/app/claim-doc-upload.

• You may mail the documentation to our office at the address listed below:

OREGON DEPARTMENT OF STATE LANDS

UNCLAIMED PROPERTY SECTION
775 SUMMER ST NE STE 100
SALEM, OR 97301-1279

If you have any questions or concerns about the information required on the claim form, please contact our
office (503) 986-5200.